Implementation of Robotic Coronary Surgery after Established Mitral Robotic Program

Morpho-Functional Features of the Radial Artery: Implications for Use as a Coronary Bypass Conduit

Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study.

Commentary: Robotic totally endoscopic coronary artery bypass: State of an art.

In a 1998 survey of New York metropolitan area anesthesiologists, surgeons, and cardiologists, the three specialties were in general agreement that important purposes of a cardiology consultation are to treat an inadequately treated cardiac condition before surgery (e.g., unstable angina or congestive heart failure [CHF]), to provide data to use in anesthesia management (e.g., ischemic threshold of tachycardia on stress test or left ventricular ejection fraction), and possibly to diagnose a medical condition before surgery (e.g., the cause of a new-onset atrial fibrillation). The yield of a cardiology consultation, in terms of new therapy or significant effect on patient management strategy prior to surgery, has, however, been reported to vary widely from 10% to more than 70%. The reasons why the consultation process often falls short of ideal are probably multifold, but may often originate from vague understanding of the consultation process. The physician initiating the consultation, whether an anesthesiologist or a surgeon, may not make it clear to the cardiologist why the consultation is being sought. In a retrospective review of 202 cardiology consultations at a university hospital, it was found that 108 just asked for an “evaluation,” 79 asked for a “clearance,” and 9 did not specifically request anything. Only six posed a specific question. As a result, the consultant often makes broadly inclusive, general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not influence the patient’s outcome but prolongs the hospital stay. In this review are presented (1) the indications for cardiology consultations as implied in the American College of Cardiology–American Heart Association (ACC–AHA) guidelines on preoperative cardiac evaluation, and (2) suggestions on how the ACC–AHA guidelines may be critically applied to, and improve, the consultation process. Preoperative Cardiac Consultation Based on the ACC–AHA Guidelines The ACC–AHA guidelines on preoperative cardiac evaluation were published initially in 1996 and were also endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Vascular Surgery. An updated version of the guidelines was published in 2002. The guidelines were based on the then-available literature as well as expert opinions from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing. The guidelines provided an 8-step algorithm for stratifying the patient’s risks and triaging to either surgery or cardiac evaluation. The first three steps of the guidelines consider the urgency of the operation and the recency of cardiac evaluation and intervention. If the operation is not emergent and if there has not been recent cardiac evaluation and/or intervention with no significant interim changes, then the remainder of the guidelines are applied. Steps 4 through 7 deal with an assessment of the patient’s clinical predictors of cardiac risk, functional status, and the risk of the surgery proposed. Step 8, or noninvasive cardiac testing to further define the patient’s risk, is indicated (1) if the patient has a major clinical predictor, (2) if the patient has an intermediate clinical predictor and either has poor functional status or is undergoing a high-risk surgery, or (3) if the patient has poor functional status and is undergoing a high-risk surgery. As defined by the ACC–AHA, major clinical predictors are unstable coronary syndrome, decompensated congestive heart failure (CHF), significant arrhythmias, and severe valvular disease. Intermediate clinical predictors are mild angina pectoris, history of myocardial infarction (MI) or CHF, diabetes mellitus, and chronic renal failure with serum creatinine greater than 2 mg/dl. A high-risk surgery carries a greater than 5% perioperative risk of cardiac events such as MI, CHF, or death and is exemplified by emergent major operations, especially in the elderly, aortic, and other major vascular procedures, peripheral vascular bypass procedures, and anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss. An intermediate-risk surgery carries 1–5% perioperative risk of cardiac events and is exemplified by carotid endarterectomy, intraperitoneal and Director of Vascular Anesthesia, Department of Anesthesia & Critical Care, Beth Israel Deaconess Medical Center, and Associate Professor of Anaesthesia, Harvard Medical School.

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery

Cardiopulmonary bypass-induced systemic inflammatory reaction involving the expression of neutrophil surface adhesion molecules is the main mechanism leading to myocardial ischemia-reperfusion injury as well as multiorgan dysfunction. Patients undergoing prolonged cardiopulmonary bypass are especially at risk in this regard. The aim of this prospective, randomized study was to evaluate the impact of continuous leukocyte filtration on the perioperative expression of neutrophil adhesion molecules along with the markers of systemic inflammation during combined coronary artery revascularization and aortic valve surgery due to aortic stenosis. Twenty patients scheduled for combined coronary artery revascularization and aortic valve surgery due to aortic stenosis were randomized to undergo cardiopulmonary bypass with or without a leukocyte filter (LeukoGuard LG6). The expression of neutrophil adhesion molecules and proinflammatory cytokine response were measured. The use of the leukocyte filter significantly increased neutrophil CD11b expression (Pg = .003) compared to the control group, which was followed by a faster rise in interleukin-6 levels 5 minutes (median, 125 versus 34 pg/mL) and 2 hours after cardiopulmonary bypass (median, 158 versus 92 pg/mL, Pt x g < .001), respectively. No marked differences in terms of levels of CD11a, CD62L, cardiac troponin-I, or oxyhemodynamics were observed. The observed increased neutrophil activation and enhanced inflammatory response do not support the use of continuous leukofiltration in patients undergoing prolonged cardiopulmonary bypass.

Background and objective The incidence and clinical impact of perioperative myocardial infarction during coronary artery bypass graft surgery vary greatly depending upon the diagnostic criteria applied. Fatal perioperative myocardial infarction has a less arguable diagnosis and clinical impact. The aim of this paper is to find out the risk factors for fatal myocardial infarction after coronary surgery. Methods Data from 1561 consecutive patients, who underwent coronary revascularization during a 10-month period, have been retrospectively analysed. After an univariate analysis for pre- and intraoperative risk factors, a multivariate model (logistic regression analysis) was settled. Results Preoperative use of subcutaneous/intravenous heparin, a heparin sensitivity index < 1.3 and need for a thromboendarterectomy of the left anterior descending coronary artery are independent risk factors for fatal myocardial infarction. The relative risk for fatal myocardial infarction was about 2 in the case of preoperative heparin use or heparin sensitivity index < 1.3 and 5.5 in the case of thromboendarterectomy of the left anterior descending coronary artery. Conclusions In patients undergoing coronary artery bypass surgery, preoperative anticoagulation management with heparin may represent a risk factor for fatal myocardial infarction. Patterns of heparin resistance, whether or not due to heparin pretreatment, seem to be closely related to fatal myocardial infarction.

Clopidogrel did not inhibit platelet function early after coronary bypass surgery: A prospective randomized trial

Off-Pump Coronary Revascularization: Operative Technique

This article discusses current shortcomings in coronary artery bypass surgery and ways to overcome them. Minimally invasive coronary bypass surgery, robotic coronary bypass, and hybrid approaches aim to avoid sternotomy, employ arterial grafts, and minimize the use of cardiopulmonary bypass. Other considerations such as bypass graft validation, the optimization of guideline-directed medical therapy, and the development of coronary surgery specialists are also crucial to further the benefits of coronary artery bypass grafting on future patients. Coronary artery bypass grafting must become less invasive, be better validated, and be carried out with an even higher emphasis on quality, including graft validation and preoperative/postoperative optimization, if it is to remain the best treatment for advanced, severe coronary artery disease.

One of the challenges in comparing the cost of off-pump coronary artery bypass surgery to conventional coronary artery bypass graft surgery with cardiopulmonary bypass is that most data are from observational studies, not randomized controlled trials. Thus, cost differences observed between groups may not be attributable to the difference in surgical technique, but to the underlying patient characteristics that ultimately led the patient to be selected to receive one procedure or another. The purpose of this study was to control for patient selection effects in observational data and estimate reductions in costs and length of stay attributable to the off-pump coronary artery bypass procedure. We studied 1172 patients (245 off-pump coronary artery bypass and 927 coronary artery bypass graft) undergoing coronary bypass graft surgery via a median sternotomy at the Lehigh Valley Hospital between January 1, 1999 and June 30, 2000. Propensity scores were used to match patients who received off-pump coronary artery bypass surgery to similar coronary artery bypass graft surgery patients. Logistic regression was used to estimate propensity scores and select 181 patients from the coronary artery bypass graft group for comparison to patients in the off-pump coronary artery bypass group. Statistical comparisons of continuous outcomes were made using the Student t test after a transformation to natural log scale to correct skewness. Patients in the off-pump group tended to be treated by surgeons with more experience with off-pump surgery (p=0.0001), relatively older (p-0.001), had fewer diseased vessels (p=0.0001), did not have previous coronary artery bypass graft surgery (p=0.01), and had elective (p=0.0002) or urgent (p=0.002) surgery rather than emergent or salvage surgery. Propensity score matched coronary artery bypass graft patients had significantly longer total LOS (p=0.02), postoperative length of stay (p=0.03), and total costs (p=0.016) than patients who underwent off-pump coronary artery bypass surgery. After correcting for selection effects, off-pump coronary artery bypass surgery was associated with 12% lower total costs, 14% fewer total and postoperative hospital days. This suggests that coronary artery bypass surgery without cardiopulmonary bypass is cost-saving at a large academic community medical center. Future research should consider whether off-pump coronary artery bypass surgery is also cost-effective.

WHAT KINDS OF PATIENTS WITH CORONARY ARTERY DISEASE ARE TREATED WITH MULTIVESSEL PERCUTANEOUS INTERVENTION VERSUS BYPASS SURGERY? A PROVINCE-WIDE FIELD EVALUATION IN QUÉBEC HOSPITALS WITH ON-SITE CARDIAC SURGERY

Is what's good for the gander good for the goose?

We investigated the impact of cardiopulmonary bypass pump (CPB), hematocrit, gender, age, and body weight on blood use in patients undergoing coronary artery bypass graft surgery at a major university hospital. Participants were 1235 consecutive patients undergoing primary coronary artery surgery over a period of 2 yr (1999 and 2000); 681 patients underwent coronary surgery with use of CPB, and 554 patients underwent off-pump coronary artery bypass surgery using a median sternotomy incision. There were 881 males and 354 females. Average packed red blood cells (PRBC) transfusion for patients on CPB was 3.4 U compared with 1.6 U for the off-pump group (P = <0.001). Patients on CPB received more frequent PRBC transfusion (72.5%) compared with 45.7% of off-pump patients (P = <0.001). Average PRBC transfusion for males was 2.2 U compared with 3.6 U for females (P = <0.001). A lower percentage of males (52.6%) than females (79.4%) received transfusion (P = <0.001). The impact of CPB, off-pump status, preoperative hematocrit <35%, gender, age >or=65 yr, and weight <or=83 kilograms using median values as cut points, on blood use was examined using logistic regression models. Use of CPB, preoperative hematocrit, (<35%) female gender, increasing age, and decreased body weight were significant predictors of transfusion (P = <0.001). Preoperative hematocrit <35% and use of CPB were the strongest predictors of PRBC transfusion. We examined the impact of cardiopulmonary bypass, preoperative hematocrit, gender, age, and body weight on blood use in patients undergoing primary coronary artery bypass surgery at a tertiary care institution. We found that all five of these variables are significant predictors of blood use in patients undergoing coronary artery bypass surgery.

Coronary artery bypass grafting (CABG) is one of the most studied operations in medical history, but many of the data forming the basis for clinical decisions in patients with coronary artery disease (CAD) were derived in the 1970s and 1980s, when the procedure and medical therapy were in their relative infancy. Advances in medical therapy (beta adrenergic blockers, thienopyridines, statins, and others), percutaneous coronary interventions (PCI), and surgical techniques have changed the decision making for patients with CAD. In addition, patient populations referred for surgery have changed since the original studies documenting advantages of CABG over other forms of therapy. Since percutaneous transluminal coronary angioplasty (PTCA) was introduced, significant advances have been made in the percutaneous treatment of CAD. When drug-eluting stents (DES) were introduced in the early 2000s, many predicted the demise of CABG surgery. Enthusiasm for percutaneous treatment of CAD has most recently led to promoting PCI for unprotected left main coronary artery (LMCA) disease, an anatomical state typically reserved for CABG [1-3]. Percutaneous options have indelibly changed the face of CABG surgery and raise questions concerning the “gold standard” of care in coronary revascularization. For instance, recent reports document that patients referred for redo coronary artery surgery have declined, presumably due to the increased enthusiasm, possibly among surgeons themselves, for PCI in this setting [4]. Despite this, few studies have actually compared PCI with CABG. Two notable studies are recently available, both demonstrating advantages for CABG over PCI for left main CAD and/or three-vessel CAD [5, 6]. Concurrently, details pertaining to short-term outcomes of CABG have been questioned. For example, historical saphenous vein graft (SVG) patencies were reported as approximately 50% at 10 years [7]. However, several studies published in the mid-2000s indicate that earlyterm patencies of aorto-coronary SVG conduits are not as good as the historical figures that are still often quoted [8-10]. While the long-term patency and performance of the left internal mammary artery (LIMA) has not been questioned, the recent poor performance of